Analysis of trends in nurse practitioner billing for emergency medical services: 2015-2018.

STUDY OBJECTIVE: Despite projections of an oversupply of residency-trained emergency medicine physicians by 2030 and amidst intensifying national debate over Nurse Practitioner (NP) qualifications to practice independently and unsupervised, NPs are increasingly staffing Emergency Departments (EDs) as hospitals seek to contain costs while simultaneously expanding services. We sought to characterize NP practice in the ED by examining NP independent billing by level of severity of illness, and relationship to practice authority, State Medicaid expansion status, and rurality. METHODS: Medicare provider utilization and payment data between 2015-2018 was used to explore NP billing as compared to five other clinician provider types for common emergency services acuity codes (CPT codes 99281-99285) to determine services billed for levels of severity of illness and trends over time. Number of services billed by clinician provider type related to state policies on NP practice authority, location, and population characteristics was explored. RESULTS: NPs who independently billed for ED CPT codes (99282-99285), increased during this time and decreased for acuity code 99281 (minor and self-limiting). Overall, NPs saw a greater increase than all other providers in both the highest severity CPT codes of 99284 and 99285. The analysis revealed that type of clinician, state practice authority policy, number of NPs, and percent of population 65 years and older (by zipcode) and population size are positive predictors for services billed. The negative predictors were rurality, states which accepted the Medicaid expansion, having a higher number of non-English speaking residents, and non-emergency medicine clinicians. CONCLUSION: As a proportion of the providers independently billing in the ED, NPs are increasingly managing higher acuity patients as evidenced by billing percentage of the highest acuity CPT codes (99284 and 99285). During the same time period, ED MDs decreased their billing in the same categories. Current employment of NPs in the ED may not be fulfilling its original vision to care for the lower acuity patients in order to allow MDs to care for the more acutely and critically ill patients, and to increase the services for underserved populations in rural areas, those over age 65, and those with limited English language proficiency. Future research should investigate ED policies resulting in NPs as opposed to MDs seeing patients with greater severity codes.

From Brainstorming to Strategic Plan: The Framework for the Society for the Advancement of Disaster Nursing: A Work in Progress.

Professional health care societies play a critical role in promoting excellence in patient care, educating and certifying their members on evidence-based practices, and pursuing relevant research agendas to advance the science in the field. Disaster nursing is a subspecialty of professional nursing characterized by a unique knowledge base and set of skills and abilities not used in normal daily health care activities. A disaster or large-scale public health emergency creates a sudden, unanticipated surge of patients with health care needs that far exceeds the capacity of the health care system. This creates a significant burden and risk for the nurses participating in the response. Recognizing the critical need to define scope of practice and core standards for disaster nursing and to promote greater nursing leadership in disaster preparedness and response, a group of subject matter experts established a professional society to provide leadership and guidance. The strategic planning process as described by M. Kwestel et al was used as the overarching framework for describing the design, development, and implementation of the new society. Establishment of the Society for the Advancement of Disaster Nursing is a definitive step toward improving national nurse readiness in the United States.

Call to Action: The Case for Advancing Disaster Nursing Education in the United States.

PURPOSE: Climate change, human conflict, and emerging infectious diseases are inexorable actors in our rapidly evolving healthcare landscape that are triggering an ever-increasing number of disaster events. A global nursing workforce is needed that possesses the knowledge, skills, and abilities to respond to any disaster or large-scale public health emergency in a timely and appropriate manner. The purpose of this article is to articulate a compelling mandate for the advancement of disaster nursing education within the United States with clear action steps in order to contribute to the achievement of this vision. DESIGN AND METHODS: A national panel of invited disaster nursing experts was convened through a series of monthly semistructured conference calls to work collectively towards the achievement of a national agenda for the future of disaster nursing education. FINDINGS: National nursing education experts have developed consensus recommendations for the advancement of disaster nursing education in the United States. This article proposes next steps and action items to achieve the desired vision of national nurse readiness. CONCLUSIONS: Novel action steps for expanding disaster educational opportunities across the continuum of nursing are proposed in response to the current compelling need to prepare for, respond to, and mitigate the impact of disasters on human health. U.S. educational institutions and health and human service organizations that employ nurses must commit to increasing access to a variety of quality disaster-related educational programs for nurses and nurse leaders. CLINICAL RELEVANCE: Opportunities exist to strengthen disaster readiness and enhance national health security by expanding educational programming and training for nurses.

Climate Change-Related Water Disasters' Impact on Population Health.

PURPOSE: Rising global temperatures have resulted in an increased frequency and severity of cyclones, hurricanes, and flooding in many parts of the world. These climate change-related water disasters (CCRWDs) have a devastating impact on communities and the health of residents. Clinicians and policymakers require a substantive body of evidence on which to base planning, prevention, and disaster response to these events. The purpose of this study was to conduct a systematic review of the literature concerning the impact of CCRWDs on public health in order to identify factors in these events that are amenable to preparedness and mitigation. Ultimately, this evidence could be used by nurses to advocate for greater preparedness initiatives and inform national and international disaster policy. DESIGN AND METHODS: A systematic literature review of publications identified through a comprehensive search of five relevant databases (PubMed, Cumulative Index to Nursing and Allied Health Literature [CINAHL], Embase, Scopus, and Web of Science) was conducted using a modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach in January 2017 to describe major themes and associated factors of the impact of CCRWDs on population health. FINDINGS: Three major themes emerged: environmental disruption resulting in exposure to toxins, population susceptibility, and health systems infrastructure (failure to plan-prepare-mitigate, inadequate response, and lack of infrastructure). Direct health impact was characterized by four major categories: weather-related morbidity and mortality, waterborne diseases/water-related illness, vector-borne and zoonotic diseases, and psychiatric/mental health effects. Scope and duration of the event are factors that exacerbate the impact of CCRWDs. Discussion of specific factors amenable to mitigation was limited. Flooding as an event was overrepresented in this analysis (60%), and the majority of the research reviewed was conducted in high-income or upper middle-/high-income countries (62%), despite the fact that low-income countries bear a disproportionate share of the burden on morbidity and mortality from CCRWDs. CONCLUSIONS: Empirical evidence related to CCRWDs is predominately descriptive in nature, characterizing the cascade of climatic shifts leading to major environmental disruption and exposure to toxins, and their resultant morbidity and mortality. There is inadequate representation of research exploring potentially modifiable factors associated with CCRWDs and their impact on population health. This review lays the foundation for a wide array of further areas of analysis to explore the negative health impacts of CCRWDs and for nurses to take a leadership role in identifying and advocating for evidence-based policies to plan, prevent, or mitigate these effects. CLINICAL RELEVANCE: Nurses comprise the largest global healthcare workforce and are in a position to advocate for disaster preparedness for CCRWDs, develop more robust environmental health policies, and work towards mitigating exposure to environmental toxins that may threaten human health.

Progress on a Call to Action: Nurses as Leaders in Disaster Preparedness and Response.

This article provides an update on the progress of the "Call to Action: Nurses as Leaders in Disaster Preparedness and Response." A steering committee, initiated, directed, and supported by the Veterans Emergency Management Evaluation Center of the US Department of Veterans Affairs, has undertaken the work of bringing together subject matter experts to develop a vision for the future of disaster nursing. The ultimate goal is to ensure that every nurse is a prepared nurse. As one result of this work, the Society for the Advancement of Disaster Nursing has held its inaugural meeting in December 2016.

Nurses as Leaders in Disaster Preparedness and Response--A Call to Action.

PURPOSE: To develop a vision for the future of disaster nursing, identify barriers and facilitators to achieving the vision, and develop recommendations for nursing practice, education, policy, and research. DESIGN AND METHODS: A series of semistructured conference calls were conducted with 14 national subject matter experts to generate relevant concepts regarding national nursing workforce preparedness. An invitational daylong workshop hosted by the Veterans Emergency Management Evaluation Center, U.S. Department of Veterans Affairs, was held in December 2014 to expand and refine these concepts. Workshop participants included 70 nurses, emergency managers, and a broad range of public health professionals. Conference call notes and audiotapes of the workshop were transcribed and thematic analysis conducted to outline a vision for the future of nursing in disaster preparedness and response, and to articulate an agenda for nursing practice, education, policy, and research to achieve that vision. FINDINGS: The group developed a vision for the future of disaster nursing, and identified current barriers and opportunities to advance professional disaster nursing. A broad array of recommendations for nursing practice, education, policy, and research, as well as implementation challenges, are summarized in this article. CONCLUSIONS: This project represents an important step toward enhancing nurses' roles as leaders, educators, responders, policymakers, and researchers in disaster preparedness and response. Nurses and the health and human service organizations that employ them are encouraged to engage in an expansive national dialogue regarding how to best incorporate the vision and recommendations into their individual lives and the organizations for which they work. CLINICAL RELEVANCE: Nurses comprise the largest healthcare workforce, and opportunities exist to strengthen disaster readiness, enhance national surge capacity, and build community resiliency to disasters.

Conducting research during disasters.

The potential for man-made or natural disasters is a reality that exists within the confines of the global setting. Man-made and/or natural disasters, although devastating to the human population, offers researchers the ability to explore and advance current preparedness, response, and recovery practices. When conducting research, consideration must be given to the ethical treatment of vulnerable populations and the protection of privacy for those affected by the disaster.

Reconsidering "special needs" populations during a disaster.

Meeting the "special needs" of at-risk populations affected by disasters is of the utmost importance. In the United States, there are 54 million people who fit into the special needs category who are defined as handicapped, disabled, vulnerable, challenged, or having special needs. The paramount importance for the special needs population is maintaining human dignity throughout the disaster management cycle. Government agencies, nongovernmental organizations, and advocacy organizations have all worked together to attempt to address and ensure that the needs of all individuals are addressed throughout the disaster cycle. Each provider and emergency responder should be familiar with the Americans with Disabilities Act requirements, but this alone does not begin to address the needs of children, the elderly, or other individuals and their special needs. There are multiple theoretical frameworks that may be useful, but the most human approach may be to consider needs based on Maslow's hierarchy of needs.

National Assessment of Nursing Schools and Nurse Educators Readiness for Radiation Emergencies and Nuclear Events.

Nurses will play a crucial role in responding to a public health emergency resulting from nuclear war or other large-scale release of radiation into the environment and in supporting the National Health Security Strategy. Schools of nursing are ultimately responsible for developing a competent nursing workforce prepared to assess a population's public health emergency needs and respond to these low-frequency but high-impact events. This responsibility includes the provision of specific content and training regarding how to respond and care for patients and communities in the event of a nuclear or radiation emergency. To date, however, there has been a lack of empirical evidence focusing specifically on nursing schools' capacity to prepare nurses for radiation emergencies and nuclear events, as well as perception of risk. This study employed a cross-sectional survey administered to a nationwide sample of nursing school administrators and faculty to assess content, faculty expertise, planning, and perception of risk related to radiation emergencies and nuclear events.

Society for the Advancement of Disaster Nursing: Exploring the Path to Excellence.

OBJECTIVE: Major disasters occurring within the Unites States require nursing participation as a component of a successful response. Disaster nursing includes the care of populations affected by disasters, public health emergencies, and mass casualty events, both natural and man-made. A unique knowledge base, abilities, and skills are needed to respond appropriately to health care and human service needs resulting from these events. METHODS: Despite prior efforts to advance disaster nursing as a specialty, none were sustainable and a professional framework for establishing standards and guidelines remains lacking. RESULTS: Disaster nursing is a complex arena where the intersection of competence, scope of practice, regulation, and clinical guidelines continues to evolve. Professional credibility and our contribution to disaster response lie in our ability to articulate and advance professionalism. Disaster nursing as a specialty practice requires a similar foundational framework to nursing specialties recognized by the American Nurses Association within a model of professional practice in order to ensure population outcomes that are reflective of safe, quality, evidence-based practice. CONCLUSIONS: It is time to define a disaster nursing scope of practice, establish standards for care, identify best practices, and pursue the establishment of an independent professional organization within the field of disaster nursing. This will establish the necessary foundation for optimizing nursing's contribution to and support of the National Health Security Strategy. (Disaster Med Public Health Preparedness. 2017;11:641-646).

The National Response Plan: Health and Human Services the lead for Emergency Support Function #8.

On January 6, 2005, the National Response Plan (NRP) was introduced to standardize a national approach for responding to natural or man-made threats. The underlying structure for the NRP is the National Incident Management System, which establishes standardized training, organization, and communications procedures that can be used by multiple jurisdictions to interact in a disaster. The NRP clearly identifies authority and leadership responsibilities. The NRP organizes the government's emergency operations into 15 emergency support functions, of which Emergency Support Function #8 pertains to public health and medical services. The United States Public Health Service (PHS) Commissioned Corps is one of the seven uniformed services of the United States, and PHS officers can be deployed to help meet urgent public health needs when traditional mechanisms and resources are overwhelmed. The role of PHS nurses is presented.